Provider Demographics
NPI:1922826908
Name:PETERSEN, OLIVIA LARK
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:LARK
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3869 S 3050 W
Mailing Address - Street 2:
Mailing Address - City:WEST HAVEN
Mailing Address - State:UT
Mailing Address - Zip Code:84401-1997
Mailing Address - Country:US
Mailing Address - Phone:949-395-4149
Mailing Address - Fax:
Practice Address - Street 1:5320 ADAMS AVE PKWY
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-6913
Practice Address - Country:US
Practice Address - Phone:801-476-7800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-30
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist